6) Autonomous vehicles (drones) are expected to deliver drugs and other goods remotely (see Matternet). It’s possible to build a basic quadcopter with a camera for $100-200.

7) Patients are increasingly quantifying themselves and comparing their data with others. Example Crohnologyis a social network for Crohn’s Disease patients.

8) Artificial Intelligence is becoming a reality. IBM’s Watson has been training itself at Kettering Cancer Institute. IBM has made Watson available as an API that can be used by other applications. AI-based Google car (I sat in the first version in 2012) actually works quite well!

9) Most patients will have access to an Internet-enabled smart phone or tablet device and it’ll connect from everywhere. Patients will possibly even ‘wear’ a computing device.

10) Most doctors are performing some form of data-enabled, evidence-based medicine (e.g. boom in lab tests) instead of practicing on gut-feel.

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Questions to consider for ambulatory surgery centers

1) Could ambulatory surgery centers expand the ownership of the medical problem from episodic care to the source of the medical problem? For e.g. ASCs focusing on screening for colon cancer can go upstream and identify why its patients are getting colon cancer.

2) Through the aid of EHR data and virtual care, can consults pre-and-post surgery be done remotely? Could new patients be screened virtually, thereby expanding outreach by 10x or more? Outside of the insurance reimbursement model, are there other ways to monetize this? (See American Well that partners with insurances).

3) What would an ASC’s impact on its area of care be if it were to collect and document data from its expanded virtual care model?

4) What would an ongoing multi-variant analysis from different sources with abnormalities reveal for the ASC’s patient population?

5) What role do bio/ genetic markers play in the ASC’s medical area of question? Example, for eye care.

6) Is there a correlation between location and the types of patients seen at the surgery center?

7) What insights could an ASC gain if a large portion of its patients were connected to each other online?

8) What if the EHR was implemented for delivery of healthcare itself in the future and not just as a means of digital storage and quality control?

1) A group consult is very effective, even emotionally. Unlike the private nature of healthcare delivery we are used to in the developed world, a group consult can actually be highly effective – even emotionally. It helps patients realize that others are sick too and they are not alone. This somehow converts the group consult into a more supportive environment that can possibly increase patient compliance.

To describe a group consult, a patient in Trincomalee, Sri Lanka sits in front of a Skype camera and interacts with doctor(s) in Ann Arbor, Michigan while other patients wait in the background and observe. The doctor(s) go over key vitals, past history, medication list, dosages and examine latest data available and note what’s changed from the last time. They ‘look’ at the patient via Skype, ask questions (some general) with the help of a translator/ medical assistant on the Sri Lanka side. Naresh and the medical students arrive at a consensus on what to do and then they move on to the next patient.

2) One hour together is a lot of time. When a group of doctors go over each case methodically for a group of patients, a lot is actually accomplished. Time is saved. There’s a unique sense of transparency – everyone knows what is being done. Unlike in private practice medicine, there’s a different sense of teamwork among the doctors and among patients. Learning occurs both ways.

3) The mind can’t really tell the difference. Video-conferencing even via a blurry medium (in this case Skype over a moderately paced Internet connection) is very effective. Patients (and doctors) forget after a point that no one is physically in front of each other. The doctors aren’t located in a formal office – in fact, some are on their bed, some in their studies, some in their kitchen. This provides a different sense of camaraderie and in a completely different way they are welcoming the patient into a personal space. After the initial minutes, the mind actually forgets what’s virtual and what’s real. The patient-doctor interaction can get as immersive and real as a video game.

4) Using evidence-based guidelines. Given the age of patients, the focus of care has been hypertension, followed by diabetes. Readings are captured by the assistant every other day and entered into the system. We are now programming enki EHR using JNC 8 guidelines for hypertension to automatically assist during care based on age and medical background of the patient. During the group consult, the guidelines keep care-givers in check based on evidence-based protocols. The evidence-based methodology provides great balance to the human interaction enabled through a virtual consult.

5) Sometimes, virtual is better than the real thing. This past week, Naresh shared the outcome of a short survey done amongst patients. They feel well taken care of and actually prefer ‘virtual care’ over a real one. While this may be early, it’s startling and very telling. But when you think about it, it’s actually not surprising. For some patients, the alternative to ‘virtual care’ is usually bad care or even no care.

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Why this is the future and could change how healthcare is delivered

Every few decades, medicine undergoes a big shift – increasing access, life expectancy and so on. We are in the middle of another one – where medicine is becoming a more precise data science. There’s increasingly more data available about the human body – from a gross level (# of steps taken in a day to # of hours slept) to a deeper level (DNA testing to microbiome testing). Doctors are increasingly reliant on data (usually via lab tests) before making a medical judgment. Most data is always available via a patient’s electronic medical record. The ‘Internet of things’ is a very real trend (think, the Nest thermostat) and is becoming the ‘Internet of medical things’ where medical devices are Internet-enabled. Patients continue to live longer through the aid of medications and fixes at the hospital. Fewer and fewer doctors are getting into primary care where the basic flow chart of a patient’s diagnosis begins. Cost of care will continue to explode (even in the developing world) as science advances further within specialties and the influences of regulation, administration, insurance companies and law continue to rise.

The trends point to a world where access to quality and reliable healthcare will not just continue to be difficult but may also increase. The trends also point to a possible future where healthcare is accessible from anywhere through a mobile Internet connection with the aid of virtual consults and medical data through an EHR.

Medical practices continue to hesitate to share records freely with patients. There could be many reasons for such caution. Patients could use the information to sue doctors when something goes wrong. Doctors templatize information – and therefore, when someone reads it, it may not make much sense. But what if we trusted patients to do the right thing? We trust them to use the information to take better care of themselves? And we teach them to do so. Then we could get a lot back in return – not just clinical returns of healthier patients but patients could also engage better with ambulatory surgery centers and specialty groups to lower administrative costs.

Here are a few ideas where patients could help doctors lower administrative costs for the front desk and other staff members.

Patients could:

Update their demographics and insurance information through a web portal

Upload images of insurance cards, driver’s license and social security via a patient portal into the EHR

Read and sign consent forms

Pay past dues

Take clinical satisfaction surveys

Complete clinical questionnaires

Patients are the most under-utilized resources in a care setting – if we trust them enough and engage them, everyone would win.

A couple of decades later, when we look back at this time, we would more completely understand that these were the early days of healthcare IT. While majority of Americans are just about getting on digital records, large pockets of the world are largely paper-based. While most of the hospitals in the US are using hospital management systems, almost no one takes a cloud-based approach. While several medical practices are migrating to the cloud, just a minority uses a mobile platform. While large healthcare systems have figured out how to implement and use an EHR, almost no one uses the medical record as a means to deliver healthcare. While early adopters are getting access to data from their insides through DNA and microbiome tests, most doctors aren’t yet accustomed to using this information to diagnose before a disease occurs. While several families use Skype to talk to loved ones, they have never used video calling to speak to a doctor.

There are 7.2 billion people in the world today, majority of them in urban areas. There will be 1.75 billion smartphone users in 2014. It’s easy to imagine that in just a few years, most of the world will be connected via smartphones that are Internet-enabled. It would be a failure of our health systems, if we don’t take advantage of this reach to provide healthcare access everywhere.

We have been Google Glass Explorers (as early adopters are called) for several months now. We extended enki EHRto Google Glass – to provide basic medical information such as patient’s name, basic demographics, vitals, medications, allergies and endoscopy images. We did the pilot primarily to explore and understand how it would feel to use Glass in a clinical environment. We demoed this prototype at FutureMed 2013 (now called ExponentialMedicine).

At the outset, Glass is futuristic and feels very, very cool in a medical setting. Sooner or later, physicians will see patients without being occupied with a computer. But as a hardware with accompanying Glassware (what its software is called), it has its share of teething problems. The hardware heats up when a lot of data is exchanged. The software SDK is not simple enough to work with. There are several important features that are missing. However, it’s still very important for the medical community to explore how it may be used.

We are having early conversations with health systems where the discussions are usually about finding the right longterm use cases. The question that senior management at hospitals must ask themselves is actually whether they would like to experiment with wearable computers at this point or not. Every technology breakthrough occurs through a series of failed and successful experiments – at the end of which, the organization/ team can establish a strong point of view based on what they have experienced. This allows them to build the future.

For example, Google Glass may not be ready for a full-fledged rollout in the stage that it is – it’s at best suitable for a prototype amongst early adopters within a single department of a hospital. But the fact is the hardware will improve and may be within a year, it will get to a point where it becomes solidly reliable for a full-fledged rollout. But for a hospital to be ready for such a rollout, it must be willing to experiment today and be willing fail – so that it can succeed when and where it matters – in defining the future of healthcare delivery.